The Growth of Pediatric Neurosurgery in Southern Vietnam and the First Separation of Pygopagus Twins: Case Report

CASE REPORT J Neurosurg Pediatr 25:445–451, 2020

The growth of pediatric neurosurgery in southern Vietnam and the first separation of pygopagus twins: case report

Dang D. T. Can, MD,1,9 Jacob R. Lepard, MD,1,2,8 Tran T. Tri, MD,4 Tran Van Duong, MD,5 Nguyen T. Thuy, MD,6 Pham N. Thach, MD,7 James M. Johnston, MD,2,3 W. Jerry Oakes, MD,2,3 and Tran Dong A, MD4

1Neurosurgical Department, Children’s Hospital 2, and 9University of Medicine and Pharmacy at Ho Chi Minh City, Vietnam; 2Department of Neurological Surgery, University of Alabama at Birmingham; 3Section of Pediatric Neurosurgery, Children’s of Alabama, Birmingham, Alabama; 4Pediatric Surgery Department, Children’s Hospital 2, Ho Chi Minh City; 5Plastic Surgery Department, Cho Ray Hospital, Ho Chi Minh City; 6Anesthesia Department and 7Urology Department, Children’s Hospital 2, Ho Chi Minh City, Vietnam; and 8Harvard Program for Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts

Conjoined twins are a rare congenital abnormality with an estimated incidence of 1:50,000 pregnancies and 1:200,000 live births. Pygopagus twins are characterized by sacrococcygeal fusion that is commonly associated with perineal and spinal abnormalities. Management of this complex disease requires a well-developed surgical system with multidisciplinary capacity and expertise. A decade ago there were no dedicated pediatric neurosurgeons in southern Vietnam. This has changed within a few short years; there are now 10 dedicated pediatric neurosurgeons with continually expanding technical capacity. In Au- gust 2017 a multidisciplinary surgical and anesthetic team successfully separated female pygopagus twins with fused sacrum and spinal cord with associated myelomeningocele defect. The authors present here the first successful separation of pygopagus twins in Vietnam as a representative case of gradual and sustainable pediatric neurosurgical scale-up. https://thejns.org/doi/abs/10.3171/2019.11.PEDS19291 KEYWORDS global neurosurgery; pygopagus; conjoined twins; Vietnam; limited resources; pediatric neurosurgery; congenital

onjoined twins are a rare congenital abnormality either referral and transfer to centers in more developed with an estimated incidence of 1:50,000 pregnan- countries27 or investment and scale-up in local surgical cies and 1:200,000 live births and a known female capacity. Only the latter is a sustainable option. Indeed, predilectionC of 3:1.30 Pygopagus twins represent 6%–19% the Lancet Commission on Global Surgery (LCoGS) re- of conjoined twins and are characterized by sacrococ- ports that 5 billion people lack access to safe and afford- cygeal fusion that is commonly associated with perineal able surgical care when needed,15 with much of the unmet and spinal abnormalities.16 Although rare, they represent burden being neurosurgical20 and pediatric neurosurgical a complex surgical pathology often requiring expertise in disease.5 Based on this, we present here the first successful obstetrics,3,9,16 pediatric surgery,8,18,19,34 urology,11,13 neuro- separation of pygopagus twins in Vietnam as a representa- surgery,7,28 plastic surgery,14 anesthesia,24,26,32 radiology,4 tive case of gradual and sustainable pediatric neurosurgi- and critical care.12 Because of the need for nuanced mul- cal scale-up. tidisciplinary care, the successful management of these cases has often been limited to well-equipped centers in Case Report developed countries with extensive surgical and neurosurgical capacity.8,19,22,28 Thus, the occurrence of these com- Presentation and Workup plex pathologies in lower-resource settings necessitates The 2 female patients were born on July 23, 2016, in

ABBREVIATIONS CH2 = Children’s Hospital 2; LCoGS = Lancet Commission on Global Surgery. SUBMITTED May 16, 2019. ACCEPTED November 14, 2019. INCLUDE WHEN CITING Published online January 17, 2020; DOI: 10.3171/2019.11.PEDS19291.

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and conjoined spinal cord tethered by a fatty filum distally (Fig. 2C and D). Cardiopulmonary evaluation revealed no abnormalities. There was no shared vascularity and all abdominal and pelvic organs were found to be separate. Surgical Management The decision was made to delay separation until the twins were older and could better tolerate the procedure. The surgery was ultimately scheduled for August 2017. The patients were 13 months old at this time with a com- bined weight of 12 kg. Tissue expanders were implanted 1 month prior to surgery but were complicated by infection and subsequently removed without being used. The multidisciplinary team consisted of neurosurgery, pediatric surgery, plastic surgery, and anesthesia, which were separated into a “red” and “yellow” team with focus on child A and child B, respectively (Fig. 3A). The surgical plan was divided into 4 phases (Table 1). Phase 1 involved the skin flap and soft-tissue dissection and was performed by a combination of plastic surgery and neurosurgery. The patients were placed in the lateral position with the first operative side (side 1) facing up and the second operative side (side 2) facing down. Both sides were prepared simultaneously and side 2 was kept sterile by laying the patients on a sterile sheet prior to surgical draping (Fig. 3B). Using Doppler ultrasonography to identify vascular pedicles, the first M-shaped skin flap was marked to provide sufficient skin coverage to both patients postoperatively. The superficial tissue dissection was completed by the plastic surgery team. Following this the neurosurgical team exposed the myelomeningocele of child B and the lamina of both children, performing laminecto- mies as needed to fully visualize the thecal sac proximal and distal to the point of fusion. Phase 2 required exploration of the 2 spinal cords with dissection of the fused cord, FIG. 1. Physical examination of the twins demonstrating sacrococcygeal fusion (A) and perineal abnormalities (B). Figure is available in color myelomeningocele, and filum. The neural placode of child online only. B was released from the dura mater of child A and the fatty filum of the fused segment was detethered. Next, the conjoined cord was separated—with preference given to preserve child A’s normal motor function. This was com- Binh Phuoc province, a rural area of southern Vietnam. pleted under microscopic visualization (Fig. 4). Last, the The primigravid mother was 18 years old and gave birth at dura of child A and the neural placode and dura of child 33 weeks via cesarean section at a provincial hospital. She B were closed in watertight fashion. Neurophysiological had undergone no antenatal care. The total birth weight monitoring is not currently available at CH2 and was not was 3.4 kg. Four days later the twins were transferred used in this case (Video 1). to Children’s Hospital 2 (CH2) in Ho Chi Minh City for VIDEO 1. Summary of patient presentation and steps of the proce- evaluation. On initial examination they were noted to have dure. Copyright Jacob R. Lepard. Published with permission. Click fused backs and buttocks. Perineal examination demon- here to view. strated separate vaginas with a perineal fistula in the case In phase 3 the patients were rotated 180° to facilitate of child A and a rectovestibular fistula in the case of child complete separation of the perineum. This was accom- B. Synarthrosis of the right knee was noted in child B, plished by obtaining hemostasis, packing the surgical as well as congenital hip dysplasia (Fig. 1). Neurological wound on side 1, and then removing the outer surgical examination demonstrated no abnormalities for child A drapes to expose the underlying sterile sheet. A sterile and paraplegia for child B. Urodynamics were not avail- plastic bag was then placed and sealed with tape so that able. Abdominal ultrasound demonstrated no evidence of it contained the legs and lower trunks of both patients as bladder or ureter dilation. CT was performed, which dem- well as the packed surgical wound. Then with involvement onstrated a fused sacrum with intact spinal lamina in child of both red and yellow surgical and anesthesia teams the A and spinal laminar defects with associated myelome- patients were carefully rotated 180° so that side 1 was fac- ningocele in child B (Fig. 2A and B). MRI confirmed the ing the underlying sterile sheet and side 2 was facing up. presence of myelomeningocele in child B and spinal fu- Following this an identical M-shaped incision was made sion in the proximal sacrum resulting in a single thecal sac on side 2 and the perineal dissection was done so that the

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FIG. 2. A: 3D CT reconstruction of sacrococcygeal fusion. B: Sagittal CT demonstrating intact lamina of child A and laminar defects with associated myelomeningocele (asterisk) of child B. C: Sagittal T2-weighted MRI sequence demonstrating distal spinal cord fusion and tethering. D: Sagittal T2-weighted MRI sequence showing the myelomeningocele defect in child 2. Figure is available in color online only. twins were separated completely. In phase 4 each patient Discussion was placed prone in separate but adjacent operating rooms The Growth of Pediatric Neurosurgery in Vietnam and underwent a rotational myofascial gluteal flap followed by interlocking closure of the 2 M-shaped skin flaps Neurosurgery in Vietnam was jointly founded by Dr. Nguyen Thuong Xuan in Hanoi in 1956 and by Dr. Dang in each patient. Finally, the patients were rotated to the 1 supine position for a diverting colostomy by the pediatric Van Chieu in 1958 in Ho Chi Minh City (Saigon). Over surgery team to conclude the procedure. the following decades Vietnamese neurosurgery has expanded significantly with 2 high-volume neurosurgical Outcome and Follow-Up training centers in the north and south based out of Viet Duc Hospital in Hanoi and Cho Ray Hospital in Ho Chi Postoperatively the patients retained their baseline level 10 of neurological function, with child A having no new motor Minh City, respectively. As of now there are an estimat- deficits or incontinence. Child B remained paraplegic with- ed 600 neurosurgeons serving Vietnam’s population of out bladder continence, which was unchanged from prior to 90,728,900, giving a density of 0.661 neurosurgeons per surgery. At the 2-week follow-up child A was found to have 100,000 population (see https://www.wfns.org/menu/61/ a CSF leak. This was treated with surgical exploration fol- global-neurosurgical-workforce-map). Despite this growth lowed by temporary ventricular and lumbar drainage and there has been limited expansion of pediatric neurosurgi- subsequently resolved without requiring further interven- cal expertise, with the majority of pediatric neurosurgi- tion. The children continue to have scheduled outpatient cal capacity being based in the northern region at Hanoi’s follow-up with all surgical providers to ensure continued National Hospital of Pediatrics. In 2011 the first dedicated improvement and to observe for delayed complications. At pediatric neurosurgical department in southern Vietnam 1 year after surgery the patients are doing well at home and was established by Dr. Dang Do Thanh Can at the CH2 in meeting appropriate developmental milestones. Ho Chi Minh City.

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FIG. 3. A: The multidisciplinary surgical and anesthetic team. B: Side 1 and side 2 being prepped simultaneously on sterile sheets prior to draping. Figure is available in color online only.

Initially, the procedural capacity was limited to trau- ease, craniofacial surgery, and flexible endoscopy for pe- ma and basic management of tumor, hydrocephalus, and diatric hydrocephalus. Currently the department of pedi- vascular disease due to a lack of microsurgical equip- atric neurosurgery at CH2 performs 600 procedures per ment. In just 8 short years the department has expanded year, with 400 categorized as elective and 200 as emer- to include 10 dedicated pediatric neurosurgeons with 2 gency procedures. operative microscopes and the capability of performing complex microsurgical dissection of intraventricular and pineal region tumors, arteriovenous malformations, and Surgical Separation in Resource-Limited Settings advanced craniofacial pathology. Through consistent It is estimated that only 25 separations of pygopagus mentorship and partnerships with outside institutions twins have been performed to date,35 with several de- such as the University of Alabama at Birmingham,21 scribed in resource-limited settings. Indeed, other cases Ochsner Medical Center, and CURE International,6 the of successful pygopagus separation have been reported technical capabilities have grown to include surgical from low- and middle-income countries such as Nigeria,1 treatment of refractory epilepsy, complex vascular dis- Rwanda,17 India,19 and the Phillipines.25 Additionally, sev-

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TABLE 1. Summary of the surgical plan divided by phase, specifying participating surgical teams and goals of each phase Phase Surgical Teams Goals 1 Plastic Surgery & 1. First M-shaped skin flap on side 1 Neurosurgery 2. Dissection from skin to muscle (Plas- tic Surgery) 3. Exposure of dural sac & meningocele defect (Neurosurgery) 2 Neurosurgery 1. Exploration of both spinal cords, filum, & myelomeningocele 2. Release the neural placode of child B from surrounding dura 3. Detether the conjoined fatty filum 4. Separate the fused cord 5. Close all dural sacs 3 Pediatric Surgery & 1. Obtain hemostasis & pack surgical Plastic Surgery wound 2. 180° rotation 3. Second M-shaped skin flap on side 2 4. Final separation of perineum & transfer to separate operating rooms 4 Plastic Surgery & 1. Rotate the twins to prone position Neurosurgery 2. Rotational myofascial gluteal flap 3. Closure of skin incisions in interlocking fashion 4. Rotate the twins to supine position 5. Diverting colostomy

eral large series exist from well-equipped and highly ex- perienced centers such as Cape Town in South Africa22 and São Paulo in Brazil.31 Notably, one separation of ischiopagus twins has been previously undertaken in Viet- nam.33 However, our current case is unique from this prior report due to the extensive CNS involvement and necessity of pediatric neurosurgical expertise. There were several technical aspects of the case that increased the complexity from a neurosurgical perspec- tive. First, the presence of the myelomeningocele defect in child B made the dissection significantly more difficult. Awasthi et al. reported a case of pygopagus twins with spi- na bifida; however, the extent of the defect was limited to bony abnormalities without the presence of a myelomeningocele.2 In our case the myelomeningocele was ultimately FIG. 4. Intraoperative views. A: Exposure of the meningocele and conjoined thecal sac. B: Opened dura revealing cord fusion. C: Plane managed with microneurosurgical dissection followed by of cord separation giving preference of functional tissue to the neurologi- standard dural reconstruction and closure (Video 1). Next cally intact child A (dashed line). Figure is available in color online only. was the ethical deliberation regarding which twin should be given preference in terms of functional neurological tissue. Ethical concerns regarding conjoined twins are not uncommon.29 However, the discussion necessary to reach a mutual decision between the family and medical team is standard of complexity for multidisciplinary surgical challenging in a developing world setting in which there care in Vietnam. Although the surgical separation was an is limited lay understanding of the capabilities and limita- important accomplishment, the continued follow-up and tions of medical care. long-term management of such patients is equally impor- Last, it is significant that this case was managed en- tant. At 1 year postoperatively the follow-up mechanisms tirely by the team of Vietnamese surgeons without assis- have worked well. However, this will need to be continued tance from foreign surgeons. The unique effort of cho- throughout the patients’ childhood in order to prevent de- reographing and rehearsing each stage of the procedure layed complications related to urological and orthopedic among multiple surgical specialties and teams sets a new sequelae.

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Implications for Pediatric Neurosurgical Workforce tinue to be a priority for the international neurosurgical The LCoGS recommends the availability of safe and community. affordable delivery of essential surgical procedures within 2 hours of home.15 In the present case the twins were born Acknowledgments in a neighboring province only 120 kilometers from Ho This study was completed while Jacob R. Lepard was a Wil- Chi Minh City. Although separation of pygopagus twins son Family Clinical Scholar. Funding for international travel was hardly represents “essential surgical care” in comparison provided by the Children’s of Alabama Global Surgery Program to more commonly needed procedures such as laparoto- (www.childrensal.org/global-surgery-program). my, cesarean section, or craniotomy, the capability of performing this operation nonetheless represents an impor- References tant level of sophistication and overall surgical capacity 1. Adejuyigbe O, Sowande OA, Olabanji JK, Komolafe EO, for Vietnam. The multidisciplinary expertise displayed in Faponle F, Adetiloye VA, et al: Successful separation of two this case speaks strongly to the successful scale-up of the pairs of conjoined twins in Ile Ife, Nigeria: case reports. East surgical system as a whole. Another finding of the LCoGS Afr Med J 82:50–54, 2005 is that 33 million individuals annually face catastrophic 2. Awasthi R, Iyengar R, Rege S, Jain N: Surgical management financial expenditure to pay for surgical and anesthesia of pygopagus conjoined twins with spinal bifida. Eur Spine J care.15 By performing this procedure close to home and 24 (Suppl 4):S560–S563, 2015 within the local medical system, the out-of-pocket care 3. Brizot ML, Liao AW, Lopes LM, Okumura M, Marques MS, Krebs V, et al: Conjoined twins pregnancies: experience with costs were negligible and the direct and indirect costs of 36 cases from a single center. Prenat Diagn 31:1120–1125, traveling abroad for care were mitigated. 2011 Regarding the pediatric neurosurgical aspects of the 4. Cook A, El-Gohary A, Khoury AE: The use of a three- case, it is important to note that such an undertaking would dimensional imaging model to optimize the operative not have been possible locally just 10 years prior. Indeed, separation of pygopagus conjoined twins. J Pediatr Urol an important publication in 1997 by Drs. Rosenfeld and 1:321–325, 2005 Xuan, the latter one of the founders of neurosurgery in 5. Dewan MC, Baticulon RE, Rattani A, Johnston JM, Warf Vietnam, shed important light on the current local status BC, Harkness W: Pediatric neurosurgical workforce, access 23 to care, equipment and training needs worldwide. Neurosurg of the field. The workforce at that time was described Focus 45(4):E13, 2018 as having exceptional technical proficiency but with sig- 6. Dewan MC, Onen J, Bow H, Ssenyonga P, Howard C, Warf nificant need of advanced surgical equipment and subspe- BC: Subspecialty pediatric neurosurgery training: a skill- cialty mentorship. Xuan quite prophetically observed that based training model for neurosurgeons in low-resourced “over the next decade, it is likely that, with strong inter- health systems. Neurosurg Focus 45(4):E2, 2018 national pressures, neurosurgery in Vietnam will develop 7. Fieggen AG, Dunn RN, Pitcher RD, Millar AJW, Rode H, Peter JC: Ischiopagus and pygopagus conjoined twins: neuro- rapidly into the microneurosurgery era.” This case report, surgical considerations. Childs Nerv Syst 20:640–651, 2004 as well as countless other unreported cases, serves as ful- 8. Fowler CL, Pulito AR, Warf BC, Vandenbrink KD: Separa- fillment of that statement. tion of complex pygopagus conjoined twins. J Pediatr Surg It is worth noting that the previous paradigm for care 34:619–622, 1999 of such complex cases would involve the assistance and 9. Gul A, Aslan H, Ceylan Y: Prenatal diagnosis of pygopagus primary management by foreign surgeons or transporting tetrapus parasitic twin: case report. BMC Pregnancy Child- the patient to have the procedure performed internation- birth 4:13, 2004 10. Karras CL, Tran HM, Dornbos D III, Nguyen P, Nimjee SM, ally. Neither option provides a sustainable solution to the Prevedello DM, et al: Inside Vietnam’s largest neurosurgery local deficit of surgical expertise, and more immediately, department. World Neurosurg 105:122–125, 2017 no mechanism for cohesive follow-up and long-term care. 11. Kim SS, Waldhausen JHT, Weidner BCS, Grady R, Mitchell The expansion of pediatric neurosurgical expertise to M, Sawin R: Perineal reconstruction of female conjoined southern Vietnam represents an important landmark in twins. J Pediatr Surg 37:1740–1743, 2002 neurosurgical coverage; however, there is still much work 12. Kobylarz K: Intensive care of conjoined twins. Anaesthesiol to be done in the country and surrounding region. Addi- Intensive Ther 46:130–136, 2014 tionally, as neurosurgical expertise in countries like Viet- 13. Lazarus J, Raad J, Rode H, Millar A: Long-term urological outcomes in six sets of conjoined twins. J Pediatr Urol nam and Thailand continues to develop and strengthen 7:520–525, 2011 it will be important for that knowledge to spill over into 14. McDowell BC, Morton BE, Janik JS, Gerow RK, Handler surrounding countries like Laos and Myanmar, where the MH, Lowenstein AD, et al: Separation of conjoined pygopa- neurosurgical workforce is still in its foundational phases gus twins. Plast Reconstr Surg 111:1998–2002, 2003 of growth. 15. Meara JG, Leather AJM, Hagander L, Alkire BC, Alonso N, Ameh EA, et al: Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development. Conclusions Lancet 386:569–624, 2015 The separation of pygopagus twins is a technically dif- 16. Mian A, Gabra NI, Sharma T, Topale N, Gielecki J, Tubbs ficult procedure requiring multidisciplinary expertise. Its RS, et al: Conjoined twins: from conception to separation, a review. Clin Anat 30:385–396, 2017 successful completion in southern Vietnam is a significant 17. Nyundo M, Jahn A, Kayondo K, Ntirenganya F, Muzungu marker of effective and sustainable expansion of the surgi- K, Ntakiyiruta G, et al: Successful separation of conjoined cal system as a whole. Pediatric neurosurgical expertise pygopagus twins in African environment with limited re- has expanded considerably in this region and should con- sources. Rwanda Med J 69:47–50, 2012

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18. O’Neill JA Jr, Holcomb GW III, Schnaufer L, Templeton JM 31. Tannuri ACA, Batatinha JAP, Velhote MCP, Tannuri U: Con- Jr, Bishop HC, Ross AJ III, et al: Surgical experience with joined twins: twenty years’ experience at a reference center thirteen conjoined twins. Ann Surg 208:299–312, 1988 in Brazil. Clinics (São Paulo) 68:371–377, 2013 19. Pai K M, Naidu RC, Raja A, Rai YS, Kumar N, Kini A, et al: 32. Thomas JM, Lopez JT: Conjoined twins—the anaesthetic Surgical nuances in the separation of craniopagus twins— management of 15 sets from 1991–2002. Paediatr Anaesth our experience and a follow up of 15 years. Neurol India 14:117–129, 2004 66:426–433, 2018 33. Tran DA: Successful separation of ischiopagus tripus con- 20. Punchak M, Mukhopadhyay S, Sachdev S, Hung YC, Peeters joined twins with one twin suffering from brain damage. J S, Rattani A, et al: Neurosurgical care: availability and ac- Pediatr Surg 28:965–968, 1993 cess in low-income and middle-income countries. World 34. Votteler TP, Lipsky K: Long-term results of 10 conjoined Neurosurg 112:e240–e254, 2018 twin separations. J Pediatr Surg 40:618–629, 2005 21. Rocque BG, Davis MC, McClugage SG, Tuan DA, King DT, 35. Winder M, Law A: Separation of pyopagus conjoined twins: Huong NT, et al: Surgical treatment of epilepsy in Vietnam: a New Zealand neurosurgical experience. J Clin Neurosci program development and international collaboration. Neu- 13:968–975, 2006 rosurg Focus 45(4):E3, 2018 22. Rode H, Fieggen AG, Brown RA, Cywes S, Davies MRQ, Hewitson JP, et al: Four decades of conjoined twins at Red Disclosures Cross Children’s Hospital—lessons learned. S Afr Med J The authors report no conflict of interest concerning the materi- 96:931–940, 2006 als or methods used in this study or the findings specified in this 23. Rosenfeld JV, Xuan NT: Neurosurgery in Vietnam. Surg paper. Neurol 48:307–311, 1997 24. Roy M: Anaesthesia for separation of conjoined twins. An- Author Contributions aesthesia 39:1225–1228, 1984 25. Saguil E, Almonte J, Baltazar W, Acosta A, Caballes A, Cat- Conception and design: Lepard, Can, Tri, Duong, Thuy, Thach, angui A, et al: Conjoined twins in the Philippines: experience Dong A. Drafting the article: Lepard, Can. Critically revising the of a single institution. Pediatr Surg Int 25:775–780, 2009 article: Johnston. Reviewed submitted version of manuscript: Can, 26. Sara JP, Kydes A, Pryjdun O, Jacoby M, McBride W, Pandya Duong, Johnston, Oakes, Dong A. S, et al: Anesthesia for pygopagus conjoined twins during single-twin and simultaneous pneumoperitoneum: a case Supplemental Information report. A A Pract 11:71–72, 2018 Videos 27. Shija JK, Ngiloi PJ: Final stage surgical treatment of the con- Video 1. https://vimeo.com/374397520. joined twins of Masasi, Tanzania: case report. East Afr Med J 77:172–173, 2000 Correspondence 28. Spitz L: Conjoined twins. Prenat Diagn 25:814–819, 2005 Jacob R. Lepard: University of Alabama at Birmingham, AL. 29. Spitz L: Ethics in the management of conjoined twins. Semin [email protected]. Pediatr Surg 24:263–264, 2015 30. Spitz L, Kiely EM: Experience in the management of conjoined twins. Br J Surg 89:1188–1192, 2002

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